Detroit Wayne Integrated Health Network

Clinical Specialist

• Conduct reviews of Critical/Sentinel Events to determine whether incidents meet critical event, critical incident, risk event, sentinel event, or media event criteria
• Classify critical events or incidents as sentinel or non-sentinel events
• Develop and update the MH-WIN Procedural Guidance Manual for reporting critical incidents/events, sentinel events, and deaths
• Document and report high-profile, media-reported, and urgent incidents meeting critical incident criteria
• Develop face-to-face Critical/Sentinel Event training for the provider network
• Report all expected and unexpected deaths to MDHSS within 24 hours of knowledge
• Process closure of assigned deaths in the MH-WIN Module
• Provide oversight and management of Performance Improvement Projects
• Review member records and related information, including IPOS, progress notes, psychiatric evaluations, Behavior Management Plans, dispute resolutions, grievances and appeals, and recipient rights complaints
• Follow up with providers on root cause analyses, investigations, corrective action plans, and interventions
• Maintain confidentiality and distribute peer review materials only as necessary
• Upload Critical/Sentinel Event information into MH-WIN and the All Scanned Documents tab
• Analyze and report member experience and satisfaction with services
• Develop performance improvement targets with the QI Administrator and Director
• Implement systems-improvement changes and measure and evaluate results
• Collaborate with other DWIHN units to support quality, service, and efficiency improvements
• Perform related duties as assigned

Clinical Specialist – Performance Improvement

Case Coordinator

• Monitor and manage care coordination initiatives
• Help DWIHN, its provider network, and the healthcare community progress toward a holistic, integrated, broad-ranging service model
• Follow NCQA guidelines for Complex Case Management
• Maintain a caseload of DWIHN members
• Complete required documentation in MHWIN within required time frames
• Visit members in hospital or community settings
• Complete assessments and plans of care within required time frames
• Identify eligible members through hospital inpatient lists, EMS lists, PHQ, hospital recidivism, and other sources
• Oversee marketing and education of Wayne County community providers
• Receive and respond to complex case management referrals within designated time frames
• Complete weekly and monthly reports
• Provide transitions-of-care support for members discharged from acute care settings
• Maintain compiled member lists/data for reporting requirements
• Coordinate with member care teams at the community level
• Connect members with community resources and health providers
• Assist members with applications for health benefits, SSI, Bridge Card, and related support
• Participate in care review mock audits and file reviews
• Provide care coordination for members not eligible for Complex Case Management
• Attend weekly team meetings, all-staff meetings, DWIHN meetings, designated CRSP/COPE/Children/Hospital Liaison meetings, and required training
• Perform related duties as assigned

Complex Case Coordinator

• Provide utilization management and review of services for persons served by DWIHN
• Provide clinical expertise and consultation for care coordination teams
• Facilitate integrated care delivery with providers, health homes, beneficiaries, families, community agencies, and services
• Review and coordinate complex care arrangements to ensure quality, efficiency, and optimal outcomes
• Promote integration of medical and behavioral healthcare through provider communication and collaboration
• Conduct electronic case reviews and authorize treatment plans using medical necessity criteria
• Evaluate clinical appropriateness and monitor provider treatment plans for quality and effectiveness
• Establish funding eligibility and apply priority status criteria for placement
• Determine appropriate levels of care and initiate referrals to selected providers
• Provide reauthorization for substance use disorder, mental health, and co-occurring services
• Provide behavioral health utilization management for psychiatric inpatient, detoxification, residential authorizations, and care management processes
• Assist providers with client information, appropriate referrals, and treatment-service barriers
• Ensure appropriate follow-up and aftercare plans and support continuity of care
• Monitor client compliance with services and propose alternative and creative care plans
• Participate in program enhancements and the Quality Improvement program
• Gather, document, and analyze data for desired outcomes
• Advocate for members to ensure treatment needs are met
• Identify and assess enrollees, develop and manage treatment plans, and facilitate complex care arrangements
• Perform initial and ongoing reviews of enrollees’ behavioral and physical clinical status and functioning
• Communicate with medical and behavioral providers regarding treatment planning and clinical/psychosocial needs
• Engage enrollees and providers in establishing short- and long-term goals
• Arrange care for highly complex needs, including transitions across levels of care and severe medical or behavioral conditions
• Review requests for authorization or reauthorization of medically appropriate services and length of stay
• Manage client care through the MHWIN system
• Maintain the reauthorization database with current treatment status
• Track and monitor cost factors related to service utilization, treatment activities, access, and placement criteria
• Conduct daily utilization reviews of SMI, SUD, and COD client cases
• Enter data and reports into written formats and electronic databases
• Monitor provider adherence to Federal, State, and Medicaid admission requirements
• Drive to different sites throughout Wayne County and the State of Michigan as needed
• Perform related duties as assigned

Clinical Specialist – Performance Improvement

Complex Case Coordinator

Clinical Specialist – Utilization Management